What is the recommended treatment for an adult patient with no significant medical history who has suffered an acute temple hit?

Management of Acute Temple Hit in Adults

An adult with an acute temple hit requires immediate assessment for high-risk features, and if any are present—including focal neurologic deficit, vomiting, severe headache, age ≥65 years, signs of basilar skull fracture, GCS <15, coagulopathy, or dangerous mechanism—a non-contrast head CT must be obtained. 1, 2

Immediate Risk Stratification

The temple region is particularly vulnerable to epidural hematoma from middle meningeal artery injury, making prompt evaluation critical even in neurologically intact patients. 3

High-Risk Features Mandating CT Imaging

Obtain immediate non-contrast head CT if any of the following are present:

• GCS score <15 at any point within 2 hours of injury 1
• Focal neurologic deficit (motor weakness, sensory changes, cranial nerve abnormalities) 1, 4
• Vomiting ≥2 episodes (LR 3.6 for severe intracranial injury) 1, 4
• Severe headache that is progressive or unrelenting 1, 2
• Age ≥65 years (independent risk factor regardless of other findings) 1
• Physical signs of basilar skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF otorrhea/rhinorrhea) 1, 4
• Coagulopathy or anticoagulant use (warfarin, DOACs, antiplatelet agents) 1, 5
• Dangerous mechanism: fall >3 feet or 5 stairs, pedestrian struck by vehicle, ejection from motor vehicle 1, 4
• Any decline in GCS score from initial presentation (LR 3.4-16 for severe injury) 4
• Suspected open or depressed skull fracture on examination (LR 16 for severe injury) 4, 6

Medium-Risk Features (Consider CT)

For patients with GCS 15 and no high-risk features above, consider CT if:

• Single episode of vomiting 1
• Post-traumatic amnesia (any duration) 1, 4
• Loss of consciousness (witnessed or reported) 1, 5
• Moderate headache (not severe) 1
• Visible trauma above the clavicles (significant scalp hematoma, laceration) 1

The risk of intracranial hematoma requiring surgery in this group is 1-3% 5

Low-Risk Patients (No Imaging Required)

Patients can be safely discharged without CT if they meet all of the following:

• GCS score of 15 (maintained throughout evaluation) 2, 5
• No loss of consciousness 2, 5
• No vomiting 2, 5
• No severe headache 2, 5
• Age <65 years 2, 5
• No anticoagulation or bleeding disorder 2, 5
• No focal neurologic deficits 2, 5
• No signs of skull fracture 2, 5
• Low-energy mechanism 2, 5
• Reliable caregiver available for home observation 2

The risk of requiring neurosurgical intervention in this group is definitively <0.1% 5

Discharge Instructions for Low-Risk Patients

Immediate Return Precautions

Instruct patients to return immediately if they develop:

• Worsening or severe headache unresponsive to acetaminophen 1, 2
• Repeated vomiting 1, 2
• Confusion, disorientation, or memory problems 1, 2
• Slurred speech or difficulty speaking 2
• Weakness, numbness, or vision changes 1, 2
• Seizures or convulsions 1, 2
• Unequal pupil size 2
• Clear or bloody fluid from nose or ears 2
• Increasing drowsiness or difficulty staying awake 1, 2
• Loss of consciousness at any point 2
• Behavioral changes or abnormal behavior 1, 2

Home Observation Protocol

• Check on patient every 2-3 hours for first 24 hours, including waking from sleep 2
• Avoid alcohol completely for ≥48 hours 2
• Avoid driving for ≥24 hours or until cleared by physician 2
• Avoid contact sports or fall-risk activities for ≥1 week 2
• Limit screen time (worsens headache and cognitive symptoms) 2

Pain Management

• Use acetaminophen only for headache 2, 7
• Avoid aspirin, ibuprofen, and NSAIDs for 48 hours (bleeding risk) 2
• Never prescribe opioids for post-traumatic headache 7

Special Populations

Older Adults (≥65 Years)

Age ≥65 is itself an indication for CT imaging regardless of other findings 1, 2. These patients require:

• Lower threshold for imaging 2
• Extended observation period (higher risk of delayed bleeding) 2
• Careful blood pressure monitoring 2
• Review of all medications, especially anticoagulants/antiplatelets 2
• Home safety assessment before discharge 2

Anticoagulated Patients

Patients on warfarin, DOACs, or antiplatelet agents require CT imaging even with minor mechanisms and no other risk factors 1, 5. This represents a high-risk feature independent of clinical presentation 5

Follow-Up Care

Routine Follow-Up

• Return in 3-5 days if symptoms persist 2
• Gradual return to activities over 1-2 weeks as symptoms resolve 2
• Cognitive rest initially, then gradual resumption 2
• No return to contact sports until completely symptom-free and cleared by physician 2

Postconcussive Syndrome

If symptoms persist >3 weeks, consider postconcussive syndrome and refer to traumatic brain injury specialist 1, 7. Common symptoms include:

• Chronic headaches, dizziness, nausea 1
• Vision problems, light/noise sensitivity 1
• Depression, anxiety, irritability 1
• Memory problems, difficulty concentrating 1
• Sleep difficulties, persistent fatigue 1

Patients with postconcussive symptoms should refrain from strenuous mental or physical activity until symptom-free, potentially requiring 2-3 days off work or school 1

Critical Pitfalls to Avoid

• Do not rely on absence of loss of consciousness to rule out significant injury—1.7% of patients with GCS 15, normal examination, and no LOC still required neurosurgery 1, 7
• Do not discharge patients with depressed skull fractures based solely on GCS 15—this structural injury requires imaging and potential intervention regardless of neurologic status 6
• Do not use home observation with frequent waking or pupil checks as a substitute for appropriate imaging—this practice is not supported by evidence 1
• Do not delay CT imaging in high-risk patients to "observe" them—temporal location increases risk of epidural hematoma requiring prompt intervention 3